72 year old man

DM for 20 yrs

Visited ER via private clinic

for resting chest tightness &

exertional dyspnea for 3 days

ECG: suspicious Q in V3-6

Consulted for MPS by EM Dr

REST

10mCi

0

1. SAME DAY “PROTOCOL: REST-STRESS”

60 min

STRESS

25~30mCi

100min 130 min

STRESS

25~30mCi

0

2. SAME DAY “PROTOCOL: STRESS-REST”

15 min

REST

25~30mCi

265 295 min

Tc-99m Tetrofosmin

Satran A Nuclear Cardiology: Practical Applications. NY 2004

Kim RJ. The use of CE MRI to identify reversible myocardial dysfunction.

N Engl J Med 2000;343:1445-53

Transmurality vs. Functional Recovery

LDD Imaging

8 ECG-gating

99mTc MIBI REST

0.4mCi/㎏

0 5 min

REST AND LOW DOSE DOBUTAMINE PROTOCOL

30 min

“Rest” Imaging

Dobutamine 7.5㎍/㎏/min

0

J Nucl Cardiol 2009;16:597–604

201Tl REST

4mCi

0 4 hours

REST REDISTRIBUTION AND LOW DOSE DOBUTAMINE

Dobutamine infusion

10-15 min

“Rest” Imaging

Redistribution

0 5min

Dobutamine protocol

(0-3 min) : 5 ㎍/㎏/min

(3 min to acquisition end) : 10 ㎍/㎏/min

Increasing of

dobutamine dose

3min

Ann Nucl Med 2009; 23:197–203

LDD Imaging

5 min

Dobutamine 5㎍/㎏/min

0

STRESS

25~30mCi

0 15 min

REST

25~30mCi

265 min 295 min

1980.3. Ninoy had heart attack in jail

1980.5. Ninoy sent to Dallas for CABG

Students protested against military regime in Korea

Soliders killed people in Gwangju

Gwangju citizens did armed protest to soldiers

and defeated army for a week

No crime at all during the free days in Gwangju

1983.8.21. Ninoy assassinated

1986. 2. Cory became the 11th president of Philippines

Democratic Party of Korea campained with yellow flags

1998 Daejung Kim became president of Republic of Korea

65/M CC: for evaluation of myocardial viability PH: DM on medication for 20 yrs SH: alcohol – quit 20 yrs ago (social) smoking – quit 20 yrs ago (20 PYS) FH: nonspecific PI: exertional dyspnea for years diffuse narrowing of LAD on CAG

S

R

S R M

Nonviable myocardium

Nontransmural infarction ~ 50%

Inducible ischemia (viable myocardium)

Inducible Ischemia

Circulation 1998; 98:501–8

= most specific finding for functional recovery

Nitrates

1. Increase myocardial blood flow to

hypoperfused myocardial segments

by dilating the stenotic lumen

2. Selectively relax the epicardial (conductance)

vessels, thereby facilitating flow through

collateral channels to zones of myocardial

ischemia

3. Decrease LV preload and afterload, thereby

decrease the subendocardial compression

forces and improving subendocardial perfusion

N-13 ammonia PET study: Effect of transdermal nitroglycerin on global and regional myocardial

perfusion in patients with angiographically proven CAD

Fallen et al. Circulation 1995; 91:1381–1388.

• Subjects: 20 pts (age 30-79 yrs) with chronic stable angina

responsive to sublingual nitroglycerin

• Double-blind randomized placebo control study:

20 patients were randomly allocated to receive

a precordial skin patch containing either

nitroglycerin (Nitro-Dur 0.4 mg/h; n=10) or placebo (n=10)

NTG: nitroglycerin

P: placebo

Percent change in regional myocardial perfusion from baseline to 3 hours postpatch

for both "nonischemic” and "ischemic“ zones

: Preferential enhancement of flow to the ischemic zones with nitroglycerin

NTG

P

NTG increased myocardial blood flow in viable myocardium,

whereas blood flow remained unchanged in nonviable myocardium.

5 mg sublingual nitroglycerin (NTG)

10 min before 13N-ammonia injection

ROC curves to detect viability on F-18 FDG PET

in all dysfunctional segments

cut-off = 1.1

Sensitivity 82%

Specificity 100%

According to ROC curve analysis, a ratio of 1.1 for N-13 ammonia-NTG to

N-13 ammonia baseline was the optimal cutoff value for detection of

segmental viability, with an AUC of 0.92+0.030.

“viability”

a shift toward normal of at least two

grades or complete normalization of a

resting image compared with the initial

exercise image

Redistribution

Exercise STRESS 201Tl 2mCi

0 4 hours

STRESS/NITRATE 201Tl IMAGING

10 min

“Stress” Imaging “Rest” imaging

NITRATE ADMINISTRATION

Sublingual(0.5mg)

4 ~5 days 60 min 0

201Tl 2mCi

10 min

STRESS

2~3 mCi

0 4 hours 5-10 min

“Stress” Imaging

NITRATE ADMINISTRATION

Satran A.

Baseline SPECT

99mTc sestamibi

20~25mCi

0

BASELINE/NITRATE 99mTc IMAGING

1 hour

Nitrate SPECT

Isosorbide dinitrate(10mg)

infusion for 20 min

24 hour 1 hour

99mTc sestamibi

20~25mCi

For nitrate imaging, criteria of 99mTc sestamibi injection

1. Systolic BP dropping >20 mmHg

2. Systolic BP < 90 mmHg

3. None of 1 or 2, 15 min after the start of infusion,

and the infusion was maintained for a further 2 min

0

Tc-99m-sestamibi SPECT for myocardial viability

: Pooled data

Without Nitrate (n=308 from 13 studies)

sensitivity 79%, specificity 58%

With Nitrate (n=180 from 7 studies)

sensitivity 86%, specificity 83%

Nitrate and Viability

J Nucl Med 2006; 47:1307–11

AYOS?

SALAMAT!